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Health Sector ReformsHealth Sector Reforms

State Institute of Health and Family Welfare JaipurState Institute of Health and Family Welfare, Jaipur

Health Sector ReformsHealth Sector Reforms

• What do we mean by reforms?• What are the essential components ofWhat are the essential components of

reforms?• How do reform differ from normal

evolutionary system changes?

2SIHFW: an ISO 9001: 2008 certified Institution

Health System: Challengesy g

• Stagnant public spending on health• Between 75-90% spending by states p g y• Curative public services favor the rich• Hospitalization frequently meansHospitalization frequently means

financial catastrophe• Poor outcomes• HR shortage• CostCost


Genesis of HSR: WDR 1993 -Genesis of HSR: WDR 1993 Approaches

• Fostering environment enabling households to improve health

• Improving Government spending on Health

• Promoting diversity and competition


Hsiao’s 5 Control Knobs, 2000

Fi i P t O i ti R l ti ConsumerFinancing Payment Organization Regulation Consumer behavior


Health Sector ReformsDefinitions

Sustained, purposeful, Fundamental

A process that seeks changes in health sector policies financing andchange to improve

the efficiency equity

policies, financing, and organization of services, as well as the efficiency, equity

and effectiveness of the health

,role of government, to reach national health objectivesof the health

sector.Berman,1995

objectives.Population Council,1998Cou c , 998


Health Sector ReformsDefinitions

Health sector reform includes:• Health sector reform includes:• Improving the performance of civil service• Decentralization of power and resources• Decentralization of power and resources• Improving function of national health

ministriesministries• Broadening health financing mechanisms• Introducing managed competitiong g p• Privatization

Cassels (1997)


HSRHSR

Health sector reform is deliberate, planned and intended to make longplanned and intended to make long term, permanent changes, rather than ad hoc or emergency actiong y


Pl li f D fi i iPlurality of Definitions

“Health sector reform is nothing more than projects that have been putthan projects that have been put together and it is tied to loans from the World Bank.” (Interview former S f MOHFW M 2002)Secretary of MOHFW May 2002).


Plurality of Definitionsy

A senior official of The World Bank viewsA senior official of The World Bank views health reforms as a “group of projects that includes communicable diseases, ,Reproductive and Child Health program and Health Systems” The motivation for health sector reform as seen by the World Bank is to “promote economic efficiency, quality, reform of public sector” (Interview with Senior Bankof public sector (Interview with Senior Bank Official, The World Bank Delhi Office, March, 2002).2002).


Plurality of DefinitionsyThe EC - health sector reform is nothing more than a “mixed bag of donors, projects and the g , p jgovernment of India. Overall there is a singular lack of vision among all these actors when it comes to health sector reform ” (Interview with Senior Officialhealth sector reform. (Interview with Senior Official, European Commisssion, Delhi office, March 2002). They consider the World Bank to be setting the y gagenda guided by “some North American consultants to introduce privatisation and have designed the components of the health sectordesigned the components of the health sector reform agenda for the country”. (Interview with Sr. official, EC Delhi office, March, 2002)”


Dynamics of HSRy

Shift i i t ti l thi ki bli t• Shift in international thinking – public to private provisionExplore possibility of private sector• Explore possibility of private sector participation

• Reduction in Government expenditure• Reduction in Government expenditure• User charges

C t ti t i• Contracting out services• Tax reforms


Major Issuesj• Definition—incremental not fundamental

Th ‘ j t h’ t h lth t f• The ‘project approach’ to health sector reform • Spaces are available for negotiations at both

the central and state levels with multilateralthe central and state levels with multilateral agencies.

• Fiscal crisis at state governments - health is not ga high priority area of investment,

• Loans from bank- poor repayment capacity. • Reform process is a ‘top-down approach’.

There is little consultation with the personnel at different levels of the healthdifferent levels of the health


Major Issuesj

• Little co-ordination among donors(own priorities and agendas) on health sector reformsector reform.

• Duplication and adhocism• ‘ rights based approach’ (RCH) after rights based approach (RCH) after

ICPD not effectively transferred to the different levels of providers.

• New budget?


HSR: Principlesp

• Overseeing the needs of the entire gpopulation – pro-poor; gender sensitive and client friendly.

f• Looking forward to the health transition

• Removing the blind spot to the• Removing the blind spot to the private sector

• Focusing efforts – by ensuringFocusing efforts by ensuring quality, efficiency and accountability of health services


HSR Influencers

• Epi. Transition-Changing healthEpi. Transition Changing health scenario

• Macroeconomic situationac oeco o c s ua o• Political environment• Policy changesPolicy changes• Increasing expectations• Reducing resources and external• Reducing resources and external

influences• Donor initiativesDonor initiatives


Key Issues in HSRy

• EquityEquity• Effectiveness• EfficiencyEfficiency• Quality• Sustainability in provisioning• Sustainability in provisioning• Defining priorities• Refining policies• Refining policies• Reforming institutions


HSR: Key Elements y• Structural rather than

incremental/evolutionary change;incremental/evolutionary change;• Change in policy objectives followed by

institutional change rather thaninstitutional change, rather than redefinition of objectives alone;

• Purposive rather than haphazard• Purposive rather than haphazard change;

• Sustained and long term rather than oneSustained and long term rather than one off change;

• Political top down process led byPolitical top down process led by national, regional or local government.


Wh N d b Add dWhat Needs to be Addressed

• Human resource• Fiscal allocations• Fiscal allocations• Capacity building• Process monitoring• Process monitoring


Functions Covered by HSRy

• Governance• Provisions• Provisions• Financing• Resource Generation• Resource Generation


Basic Dilemmas in HSR:HR

No. Di t ib ti

OutputDistributionCoursesIntake

Graduates & PG?

CHC DHPHC

IPHS


Health Manpower

1073638 India Rajasthan

576542656101

5237522239 37667850

18214

ANM GNM LHV Pharmacist

Source: NHP - 2010 22SIHFW: an ISO 9001:2008 certified Institution

Nursing Schoolsg

Source: www.indiannursingcouncil.org (Nov 2012)23SIHFW: an ISO9001: 2008 certified institution

Medical EducationIndia Rajasthan

Medical College 336 10Medical College 336 10

Recognized 255 8

Non-recognized 81 2

D t l C ll 294 10Dental College 294 10

Recognized 213 7Recognized 213 7

Non-recognized 81 3

Source: MCI/DCI (2012)24SIHFW: an ISO 9001:2008 certified Institution

CHC- XI FYP vs. PG seats

25SIHFW: an ISO9001: 2008 certified institution

Source: RHS 2011/ MCI, 2012 (www.mciindia.org)

Basic Dilemmas in HSR:Fi i l ll iFinancial allocations

• States – 10% of GDP. Not in a position to increasein a position to increase allocations

• Loan repaying capacity of oa epay g capac y ostates – increase financial burden. F t l d hi• Frequent leadership changes affecting reforms.

• Corruption - an additional Co upt o a add t o aimpediment to sustainability of reformsN d f ff ti• Need for more effective donor coordination


Approach for HSR:ppChange in Financing Mechanism

• User charges• Community financing• Insurance• Private participation• Increasing resource allocation


Governance Related HSRGovernance Related HSR

Evolving standard protocols for care at P i /S /T t ttiPri./Sec./Tert. care settingsQuality assurance mechanism

C P t ti A t• Consumer Protection Act • Citizens charter for hospitals;Appropriate delegation of power toAppropriate delegation of power to PRI’s.


Approach for HSRpp

P blic sector reforms• Public sector reforms• Downsizing Public sector

P d ti it i t• Productivity improvement• Competition• Improving geographic reach• Increasing role of local Govt.(PRIs)


Approach for HSR:Approach for HSR:Changes in Health system Organization

& Mgt& Mgt.

D t li ti• Decentralization• Public private mix

C t ti t f i• Contracting out of services


HSR in India

• Started in early 1990’s• Piecemeal and incremental• Piecemeal and incremental• Gradual shift in the

organization structure andorganization, structure and delivery of health care


HSR in India

8th FYP8th FYP• Free medical care

U h• User chargers• Private sector promotion

9th FYP• Enabling PRI• Focus on public, private and

voluntary sector


HSR in India

10th FYP• Equity• Financing health care• Health insurance for BPL• HRD• Capacity building• Capacity building• Integration – single society• Quality assuranceQuality assurance• PRI empowerment• PPP• NRHM


HSR: IndiaNRHMArchitectural corrections in delivery systems in reform agenda• Promote equity, efficiency, quality and accountability

E h it b d h t h lth• Enhance community based approaches to health • Ensure public health focus• Promote new innovations methods & new approaches• Promote new innovations, methods & new approaches• Decentralize and involve local governing bodies District health societiesDistrict health societiesNGO involvementIntegration of ISM(AYUSH)Integration of ISM(AYUSH)


HSR: Areas• Decentralization • Human Resources • Financial reform • Re-organization & re-structuring through mgt. input

• Communitization• Quality assurance • ConvergenceConvergence • Public Private Partnership • GovernanceGovernance • Innovation/ initiatives


Decentralization

• Devolution of authority and responsibilityD l ti f ibilit d f ti• Delegation of responsibility and functions

• Shifting power from the central offices to i h l ffiperipheral offices

• Merger & formation of Societies, VHSC, RKSRKS

• Decentralization of Planning ProcessD t li ti f Fi i h i• Decentralization of Financing mechanism

• NGO participation in National Health ProgramsPrograms


HSR: HR ReformsIPHS norms• 2 ANMs/sub center and 1 male MPW• 2 ANMs/sub-center and 1 male MPW.• 3 nurses/ANMs per PHC, 2 MO• AYUSH staff• AYUSH staff• 9nurses/CHC plus 5 specialists & 3 to 4 MOExpanding available skilled humanExpanding available skilled human resource• Teaching institution through PPPTeaching institution through PPP• More government seats in private medical

collegesg• Reviving ANM and MPW training centers


HSR: HR Reforms

• Compulsory rural postingsCompulsory rural postings • Rural health service cadre in rajasthan• Contractual appointments• Contractual appointments • Fair transfer policy- rotational postings• Incentives for difficult areas• Incentives for difficult areas • ‘Pooling’ of medical officers

M lti killi ti f i ti t ff• Multi skilling option for existing staffs


Financial Reforms

• Raise the public expenditure on health p pfrom 1% of GDP to 2-3% of GDP

• Currently increased from .9% to 1.4%• New financing mechanisms of untied

funds, breaking the traditional Treasury route, Flexi pool

• Society mechanism for fund transfer• Untied grants to village, PHC, block,

district


Financial Reforms

• Demand side finance through Insurance• Demand side finance through Insurance RSBY,

• Conditional cash transfers (JSY)Conditional cash transfers (JSY)• Flexible financial resources to ensure

service guaranteesservice guarantees• State Government’s increase their

allocation by 10 % every year and also a ocat o by 0 % e e y yea a d a socontribute 15% to NRHM.


HSR: Structural Re-organizationg• Creation of Societies- bypass regular

tgovernment• Procedure• National/ State level technical support

organization like– NIHFW, NHSRC, SHSRC SIHFWSHSRC, SIHFW

• SHSRC established/ in process at Chhatisgarh Gujarat UttarakhandChhatisgarh, Gujarat, Uttarakhand, Punjab, Karnataka, AP, Rajasthan

• Emergency response systems- 108• Emergency response systems- 108, EMRI


HSR: Structural Re-organizationg

• Procurement initiatives – TNMSC, KMSC, Assam, UP

• National HMIS• Meaningful partnerships with the

non-governmental• providers for reaching quality health

care• Co location of AYUSH in 7244

PHCs/CHCs/District Hospitals


Communitization

C it t bilit th h• Community accountability through RKS/RMRS and community monitoring processmonitoring process

• Community Health volunteer – ASHA• PRI involvement in health care• PRI involvement in health care• Village health & nutrition days (VHND)


HSR: Quality Assurance Q y

New standards for government facilities • IPHS• ISO process, NABH & NABL

standards• Focus on service guarantees


HSR: Convergenceg

• Bridging the gaps between link dept• Envisaged horizontal and verticalEnvisaged horizontal and vertical

linkages within Health sector• Intra sectoral and Inter sectoral

integration• Mainstreaming of AYUSHg


HSR:PPP Options as HR Solutionsp

C t ti i tiContracting-in options –• Specialists (MP)Contracting-out options –• PHCs to Karuna trust in Arunachal

P d h Bih (di ti &Pradesh, Bihar(diagnostics & district planning); Gujarat (CHIRANJEEVI);Punjab( village(CHIRANJEEVI);Punjab( village level dispensaries)


HSR: Rajasthan• Jan Mangal Project 1992

Population Mission• Population Mission• Strengthening FRU’s 1994-2001

D t li d Di t i t Pl i i• Decentralized District Planning since 1995-96 RMRS Cost recovery mechanism user• RMRS- Cost recovery mechanism- user charges since 1995-96

• Life line fluid stores• Life line fluid stores• Mukhya Mantri Jeevan Raksha Kosh

BPL di d• BPL medicare cards47SIHFW: an ISO 9001: 2008 certified Institution

HSR: Rajasthanj

• Devolution of Powers to PRI’s - 90’s• Population Policy, 2000• Preparation of EDL, 1996,2000Preparation of EDL, 1996,2000• “Policy to promote private sector in

Health care facilities-2006”• Policy for contracting out PHC/ CHC

to private sectorp


• Special recruitment drive with hard duty allowancesS ji i h i li i i• Sanjivani scheme -specialist services in tribal and desert areas through health campsca ps

• Swasthya Chetna Yatra• Mukhya Mantri Balika Sambal Yojana• Free Medicines to senior citizens, BPL

and pregnant women in up to 50 bedded CHCsCHCs

• Promotion of generic medicines


• Doctor aap ke Dwar Yojana: 52 MMUs

• Charak Aapke Dwar Yojana: free surgical services at rural areas

• Rajasthan University of Health SciencesM U ith N th Sh H it l N• MoU with North Shore Hospital, New York for up gradation of infrastructure in health careinfrastructure in health care institutions and medical research cooperation


• Telemedicine (ISRO support), 6 medical college hospitals with 32 g pdistrict hospital and 1 block

• Policy to promote private investment in CHealth Care Facilities

• Contractual appointments3 M th th i t i i• 3 Months anesthesia training

• Rural Health service cadreM kh M t i Ni h lk D Y j• Mukhya Mantri Nishulk Dawa Yojana• RMSCL for purchase of drugs


Thank You

For more details log on towww.sihfwrajasthan.com

or contact : Director-SIHFW

on

[email protected]

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